A case of massive distal embolizations occluding every collateral network during percutaneous intervention for chronic iliac artery occlusion

We describe a patient with right common iliac artery occlusion who presented with intermittent claudication and underwent percutaneous transluminal angioplasty. The angiogram showed 100% occluded right common iliac artery with bridged collateral flow. After initial ballooning to the artery, the occluding plaque detached from the artery and resulted in multiple embolizations, not only to the distal external iliac artery, but also to the internal iliac artery and its branches, which supplied collateral flow to the right femoral artery. Circulation in the collateral networks from internal iliac artery and its branching to the right femoral artery diminished from the multiple embolizations. Repeat aspiration and stenting to the portion of dislodged plaque was attempted, but repeat ballooning to open the external iliac artery was unsuccessful because of decreased collateral flows and distal displacement of the embolus to the right femoral artery. Finally, all blood flow to the right femoral artery was occluded. Surgical embolectomy was successfully performed, but the patient succumbed to myonephropathic metabolic syndrome. Multiple embolizations occluding numerous collateral arteries caused acute fatal ischemia to the right limb. This case report highlights potentially fatal complication in the percutaneous intervention for chronic iliac artery occlusion.